Learn from neonates with COVID-19 What we do in China Wuhan - PowerPoint PPT Presentation

Learn from neonates with COVID-19 What we do in China Wuhan children's Hospital Lingkong Zeng

COVID-19 11/3/2020 WHO Pandemic

Wuhan children's Hospital Designated treatment center of neonatal COVID-19 30/1/2020

First case of infected neonate First case of cured and discharged

Contents 01 The routes of transmission in neonates The clinical characteristics of neonates 02 with COVID-19 The management of neonates with 03 COVID-19 How to manage the neonates 04 born to mothers with COVID-19

Part 1 The routes of transmission in the newborns

Routes of transmission Familial aggregation infection 3 late-onset infected newborns familial aggregation infection

Vertical transmission ? Two studies All samples negative for SARS-CoV-2. nasopharyngeal ,rectal swabs ,amniotic fluid, cord blood, breastmilk More evidence are needed

Part 2 The clinical characteristics and diagnosis of neonates with COVID-19

Clinical characteristics Two or three systems (respiratory, gastrointestinal, cardiovascular) involved in neonates with COVID-19.

Non-specific finding CT CXR

Neonatal case Radiation exposure? Monitor by CXR

Diagnosis Suspected Cases Patients who Have one of the epidemiological history Meet any two of the clinical manifestations

Epidemiological History In the 14 days before the onset (1) have visited or lived in communities with case reports in the country, or foreign countries (2)have contact with coronavirus infected people (3) have contact with patients with fevers or respiratory symptoms from communities with case reports in the country, or foreign countries

Epidemiological History (4) Cluster onset 2 or more cases of fever and/or respiratory symptoms within 14 days in small areas like homes, offices, classes in schools and other places

Clinical Manifestations (1) Fever, dry cough, other respiratory symptoms some children may have low or no fever (2) Shows the lung imaging features (3) In the early stage of onset, the total number of WBC was normal or decreased, or the lymphocyte count decreased;

Confirmed Cases Suspected cases with one of the pathogenic evidence: (1) Coronavirus nucleic acid is positive in rRT-PCR test (2) Viral gene sequencing is highly homologous to the known novel coronaviruses (3) Double positive results for IgM and IgG; (4) The IgG changes from negative to positive or the recovery period is 4 times and more than that in the acute phase.

Severe Cases (1) RR increase: 2-12 months RR>50 : 1 - 5 years RR>40 > 5 years RR>30 except for fever and crying (2) In resting state, SpO2 ≤95%; (3) Assisted breathing (moaning, nasal faring, three concave sign), cyanosis, intermittent apnea; (4) Disturbance of consciousness: lethargy, and convulsions; (5) Food refusal or feeding difficulty, with signs of dehydration

Critical Cases (1) Respiratory failure requiring mechanical ventilation (2) Shock (3) Combined with other organ failures

Child at High Risk (1) contact with severe coronavirus infected patients (2)Baby with underlying diseases(congenital heart, lung and airway diseases, chronic heart and kidney diseases) immunodeficiency, genetic metabolic diseases (3) Baby with long-term users of immunosuppressants (4) Babies under 3 months old.

Warning Indexes (1) Tachypnea (2) Poor mental response, drowsiness (3) Lactate increased progressively; (4) CT showed bilateral or multi lobed infiltration, pleural effusion or rapid progress of lesions in a short period of time; (5)Babies under 3 m . with underlying diseases, immunodeficiency

Part Pa rt 3 The management of neonates with COVID-19

Treatment Locations (1) Suspected patients should be quarantined in a one ward per patient manner (2) Confirmed cases can be admitted in the same ward; (3) Critically ill children should be admitted to ICU as soon as possible.

Standard precautions Hand hygiene Personal protective equipment (gloves, masks, eyewear) Cough etiquette Sharps safety Sterile instrument and devices Clean and disinfected environmental surface

Additional precautions Signage at the entrance Limited parents’ visit Using special masks or N95 respirator, gown and glove change after the procedure Maintaining windows open (no negative pressure room) Incubator for every baby

Disposal of the medical waste from the isolated room in the same way as infectious medical waste Discarding all disposable supplies if unable to appropriately clean and disinfect Terminal disinfection of the patient’s room chlorine-containing preparation spray

Monitor and fellow-up Close monitoring of cardiorespiratory status apnea, bradycardia, hypotension Cyanosis should be of great concern Close follow-up of the chest radiography in case of clinical deterioration Initialization of respiratory support if necessary Ncpap NIPPV invasive ventilation

Newborns with mild symptomatic were managed with routine care

Newborns with underlying diseases presented severe respiratory illness Premature Asphyxia Sepsis

Preterm baby with Asphyxia RDS,Sepsis,DIC Improved with Ventilate Inotropic drugs, Fluid management Surfactant therapy

Antiviral agent The efficacy of antiviral agents against SARS-CoV-2 remains controversial We do not use antiviral agents except nebulized alpha-interferon

Antimicrobial agents Appropriate antimicrobial agents should only be prescribed to the patients with the probable or confirmed bacterial infection according to the antimicrobial stewardship. Empiric use or overuse of antimicrobial agents should be avoided.

Treatment of Severe and Critical Cases Respiratory Support non-invasive ventilation 2 hours without improvements /cannot tolerate Invasive mechanical ventilation prone position ventilation, lung recruitment, ECMO Circulation Support On the basis of full fluid resuscitation, improve microcirculation, use vasoactive drugs, and monitor hemodynamics if necessary.

Treatment of Severe and Critical Cases Immunoglobulin Immunoglobulin can be used in severe cases Blood Purification Treatment plasma replacement, adsorption, perfusion, blood/plasma filtration block the "cytokine storm". Corticosteroids (controversial ) Methylprednisolone in a short period (3 –5 days), dose ﹤1– 2 mg/kg/day .

Pa Part rt 4 How to manage the neonates born to mothers with COVID-19?

The neonates born to affected mother are at risk of COVID-19 Baby isolated and fed by formula initially until the affected mothers test negative for SARS-CoV-2

In the delivery room Negative pressure ward / isolation ward Neonatal resuscitation Additional precautions (gown ,gloves, masks, eyewear) intubate Positive pressure mask

Discharge criterion It is critical to decide the discharge time Current criterion Stable with normal temperature for more than 3 days and normal CXR 2 consecutive results show negative for SARS-CoV-2 using upper airway specimen (with at least a 24-hour interval).

Discharge plan 14-day isolation 2-4w fellow-up Offered the appropriate education to parents hand hygiene/disinfection of the children waste at home.

Thank you for your attention !